Necrotizing fasciitis secondary to the insertion of a cardiac pacemaker

Case report

DECLARATIONS

Competing interests

None declared

Funding

None

Ethical approval

Not applicable

Guarantor

PS and SS

Contributorship

PS wrote the paper and was the lead investigator and came up with the idea, SS, SK and SI helped edit and write the paper. SS helped with the literature review. SI helped edit, format and write the paper. SK helped with the literature review and to write the paper

We present, to our knowledge, the first reported case of necrotizing fasciitis following insertion of a cardiac permanent pacemaker (PPM).

A 91-year-old gentleman was admitted with septic shock under the medical team. He had had a cardiac PPM inserted 10 days prior for complete heart block. He was initially treated by the GP for a postoperative superficial infection with a course of oral antibiotics at home but over the next few days he became systemically unwell. Preadmission, this patient was independent, living with his wife and had no other significant past medical history apart from the heart block.

On admission he had suffered a ventricular tachycardia-related cardiac arrest and had been successfully resuscitated. He was subsequently managed in the coronary care unit (CCU) with a diagnosis of systemic sepsis from an infected pacemaker.

While in CCU his condition deteriorated and he developed acute renal failure. It was noted that the cellulitis was becoming increasingly widespread around the pacemaker site, and was not responding to the intravenous antibiotics. There was an extremely high suspicion of necrotizing fasciitis, and the plastic surgeons were contacted for a review. The same day, he was expeditiously taken to theatre by the plastic surgical team.

Perioperative findings included the presence of murky fluid, oedema of the subcutaneous tissue and necrotic muscle around the pacemaker. This gentleman then underwent a radical debridement of the infected tissues. The infected pacemaker was removed and the patient temporarily externally paced.

Microbiology revealed the causative organisms to be Staphylococcus capitis, Streptococcus salivarius and Staphlococcus aureus. The histology from the samples gathered at the time of the procedure was consistent with a diagnosis of necrotizing fasciitis.

Following treatment in the intensive care unit, the open chest wound was closed with a split thickness skin graft, five days post-debridement. He had re-implantation of a new PPM on the contralateral (right) side two days later.

Discussion

Necrotizing fasciitis is defined as a rare, life-threatening soft tissue infection characterized by widespread, rapidly developing necrosis of the subcutaneous tissue and fascia. It has been recognized as early as the fifth century BC by Hippocrates who described the association of necrotizing fasciitis with erysipelas. ¹ The term ‘necrotizing fasciitis’ was coined by Wilson in 1952 who described it as having the classical features of infection with fascial necrosis. ²

This condition is a significant surgical emergency; the diagnosis is often elusive in the early stages and should be considered in all cases of severe cellulitis, especially those resistant to antimicrobial agents.^3,4 The delay resulting from the diagnostic challenge of necrotizing fasciitis inevitably leads to increased mortality ⁵

Implantation of a PPM is the treatment of choice for bradyarrhythmias. ⁶ The number of patients receiving a new pacemaker has been increasing on a yearly basis. ⁷ Many trials have shown that these devices decrease morbidity and mortality. ⁸ In the majority of cases it is a safe procedure associated with a low morbidity and mortality, and can be performed relatively easily with a low complication rate. However, like most procedures, complications are expected (Table 1). ⁹ Based on Poole et al.'s study, there is a quoted 0.8% risk of infection. In another recent paper, Johansen et al. looked specifically at the infection rates and risk factors associated with infection after pacemaker implantation in 46,299 patients.^9,10 They found that surgical site infection occurred in 0.482% patients. Furthermore, some important risk factors for developing infection post pacemaker implantation were identified. These include male sex, younger age and absence of prophylactic antibiotics given at the time of the procedure. In this large study, there was no mention of necrotizing fasciitis as a complication of pacemaker insertion, although the paper mentions that a number of PPM had to be removed and replaced following deep infection.

Table 1

Major and minor complications of implantable cardiac devices ⁹

Major complications	Minor complications
Death within 30 days related to procedure	Haematoma lasting <7 days with tenseness, drainage or minor dehiscence managed as an outpatient
Cardiac arrest within 24 hours of procedure	Hematomas without tenseness but requiring additional outpatient evaluation
Respiratory arrest/failure within 24 hours of the procedure requiring ventilator support or intubation	Implant related pain lasting <7 days requiring prolonged use of narcotic pain medications
Acute coronary syndrome directly related to procedure	Cellulitis treated as an outpatient with oral antibiotics
Cardiac perforation with or without pericardial tamponade, requiring pericardiocentesis or other surgical intervention	Stitch abscess
Haemothorax	Minor surgical wound findings
Stroke within 30 days of replacement procedure	Unanticipated device re-programming resulting from inadequate lead performance with significant patient symptoms or status change, excluding asymptomatic threshold changes
Haemodynamic instability during the procedure requiring unplanned intervention and/or aborting the procedure	Reversal of sedation for respiratory compromise requiring benzodiazepine or opioid receptor antagonist
Infection requiring intravenous antibiotics and or system removal/extraction	Peripheral nerve injury
Generator or lead malfunction requiring reoperation	Superficial phlebitis
Pocket revision requiring reoperation
Prolonged hospitalization attributable to the device replacement procedure
Haematoma requiring evacuation, drainage, blood transfusion, hospitalization or extension of hospital stay to treat hematoma
Hospital re-admission directly related to the generator replacement procedure
Coronary venous dissection with haemodynamic instability
Pulmonary embolus
Peripheral arterial embolus
Deep vein thrombosis
Drug reaction resulting in an aborted procedure
Cardiac valve injury
New AV conduction block developing as a result of the procedure

AV, atrioventricular

As far as we know, our patient is the first reported case of necrotizing fasciitis following pacemaker insertion. This case emphasizes the importance of early diagnosis in necrotizing fasciitis. Prompt surgical debridement following diagnosis resulted in rapid improvement in the patient's condition. The wound was successfully closed with a split thickness skin graft and a new pacemaker was inserted within seven days of the initial debridement.

This case highlights some important points. Firstly, although infection post PPM is uncommon, when significant infection does occur, timely management is vital. This involves urgent surgery to remove the infected pacemaker, administration of antibiotics and re-implantation of the device at a later stage. Secondly, in a patient with an infected PPM and profound sepsis, necrotizing fasciitis must be considered as a differential, and referred to the surgical team promptly.